Fillable Printable Commercial Driver License Medical Self-certification Form - Minnesota

Commercial Driver License Medical Self-certification Form - Minnesota

Print Name (First, Middle, Last) Date of Birth (mm/dd/yyyy)

Minnesota Driver's License Number:

Drivers who check Category 1 or Category 3 below must also submit a current medical examiner's certificate from a certified

medical examiner and any applicable waivers.

I certify my commercial operating status is--check only one category box below:

1. Are you submitting a copy of your medical examiner's certificate from a certified medical examiner?

2. Are you submitting a copy of a medical waiver?

Yes No

Driver's Signature

Date

PS33203-05 (01/14)

Please check only one of the following self-certification categories that apply to you:

Driver Information:

All CDL holders with a school bus endorsement MUST submit a current medical examiner's certificate from a certified medical

examiner.

All commercial driver's license (CDL) holders, Class A, B or C, must complete and submit this self-certification form for initial,

renewal or change in class application. Refer to the Tennessen Warning on the back of this form.

If you have any questions or concerns, contact Driver and Vehicle Services by phone (651) 297-5029.

If there is a change in your medical status or interstate/intrastate status you MUSTprovide a new self-certification form.

Please submit this completed self-certification form and your medical examiner's certificate from a certified medical examiner

and/or medical waiver, if applicable by mail: Driver and Vehicle Services Division, 445 Minnesota Street, Suite 175, St. Paul,

MN 55101-5175, by fax to (651) 297-4447 or in person at any driver exam station or driver license office that accepts

applications. Refer to the Driver and Vehicle Services Website

for a list of locations.

- over -

- - - -

Please answer the following two questions:

(Checking more than one category box will delay processing this form)

Commercial Driver License Medical Self-certification Form

MINNESOTA DEPARTMENT OF PUBLIC SAFETY

DRIVER AND VEHICLE SERVICES

445 Minnesota Street

Saint Paul, MN 55101-5175

Phone: (651) 297-5029

Web: dvs.dps.mn.gov

Instructions:

(Current medical examiner's certificate from a certified medical examiner must be submitted).

Category 1 - Non-exempt Interstate, subject to 49 CFR part 391

Category 2 - Exempt Interstate, exempt from medical examination requirements of 49 CFR part 391

Category 3 - Non-exempt Intrastate, subject to state medical examination requirements of Minn. Stat., ch. 221

Category 4 - Exempt Intrastate, exempt from state medical examination requirements listed in Minn. Stat., ch. 221

Tennessen Warning

MINNESOTA DEPARTMENT OF PUBLIC SAFETY

MINNESOTA COMMERCIAL DRIVER'S LICENSE SELF-CERTIFICATION FORM

IMPORTANT: READ THIS NOTICE BEFORE YOU COMPLETE THE FORM

Why are you being asked to share this information and how will it be used?

The Department of Public Safety (DPS) will use the information to identify you as a person, to identify your driving record, to determine your

eligibility for a driver's permit, license or identification card, prevent fraud, to access your record for any future service transactions and/or

inquiries and to comply with state and federal laws.

Minnesota Statutes §§ 171.06, 221.031, and 221.0314 and federal motor carrier safety regulations (49 C.F.R §§ 383.71 and 383.153) require

collection of this information.

State and federal laws require collection of this information

If you supply the requested information, DPS will be able to determine whether to issue you a driver's permit, license or identification card. The

information may be used by other states to make decisions about whether to issue you a driver's license, permit or identification card. The

requested information may also be used by insurance providers to determine eligibility for automobile insurance coverage.

Consequences of supplying or refusing to supply requested information

DPS releases this information to local, state and federal government agencies only as authorized or required by state and federal law. This

means that the information may be shared with the following:

How is the requested information shared with other agencies?

Social Security Administration

Selective Service System

Federal Department of Labor

Minn. Department of Human Services

Minn. Department of Revenue

Minn. Department of Commerce

Minn. Attorney General's Office

Minn. Office of the Secretary of State

Minn. Department of Natural Resources

Minn. Department of Veterans Affairs

In addition, your personal information may be disclosed as authorized by United States, title 18, section 2721.

If you don't provide the information requested, DPS cannot issue you a driver's permit, license or identification card, and your existing driving

privileges, if any, may be affected.

Permissible Uses of Motor Vehicle Data as provided in

United States Code, title 18, section 2721

For use by any government agency, including any court or law enforcement agency, in carrying out its functions, or any private person or

entity acting on behalf of a federal, state or local agency in carrying out its functions.

For use in connection with matters of motor vehicle or driver safety theft; motor vehicle emissions; motor vehicle product alterations, recalls

or advisories; performance monitoring of motor vehicles, motor vehicle parts and dealers; motor vehicle market research activities, including

survey research; and removal of non-owner records from the original owner records of motor vehicle manufacturers.

For use in the normal course of business by legitimate business or its agents, employees or contractors, but only:

(A) to verify the accuracy of personal information submitted by the individual to the business or its agencies, employees or contractors; and

(B) if such information as so submitted is not correct or is no longer correct, to obtain correct information, but only for the purposes of

preventing fraud by, pursuing legal remedies against, or recovering on a debt or security interest against, the individual.

For use in connection with any civil, criminal, administrative or arbitral proceeding in any federal, state or local court or agency or before any

self-regulatory body, including the service of process, investigation in anticipation of litigation and the execution or enforcement of judgments

and orders or pursuant to an order of a federal, state or local court.

For use in research activities, and for use in producing statistical reports, so long as the personal information is not published, re-disclosed

or used to contact individuals.

For use by an insurer or insurance support organization, or by a self-insured entity or its agents, employees or contractors, in connection

with claims investigation activities, antifraud activities, rating or underwriting.

For use in providing notice to the owners of towed or impounded vehicles.

For use by any licensed private investigative agency or licensed security service for any purpose permitted under this subsection.

For use by an employer or its agent or insurer to obtain or verify information relating to a holder of a commercial driver's license that is

required under the Commercial Motor Vehicle Safety Act, 49 U.S.C. §§ 31301-17.

For use in connection with the operation of private toll transportation facilities.

For any other use in response to requests for individual motor vehicle records if the state has obtained the express consent of the person to

whom such personal information pertains.

For bulk distribution for surveys, marketing or solicitations if the state has obtained the express consent to whom such personal information

pertains.

For use by any requester, if the requester demonstrates it has obtained the written consent of the individual to whom the information pertains.

For any other use specifically authorized under the law of the state that holds the record, if such use is related to the operation of a motor

vehicle or public safety.